Combination of C1-INH and lung surfactant for the treatment of respiratory disorders

ABSTRACT

Pharmaceutical composition for the treatment of infant respiratory distress syndrome and acute lung injury (including adult respiratory distress syndrome) which contains C1 esterase inhibitor (C1-INH) and lung surfactant which comprises a lung surfactant protein.

This application is a 371 of PCT/EP99/06845 filed 16 Sep. 1999.

TECHNICAL FIELD

The invention relates to a novel combination and method for thetreatment of disease conditions which are designated as InfantRespiratory Distress Syndrome (IRDS) and Acute Lung Injury (ALI)including Acute or Adult Respiratory Distress Syndrome (ARDS).

PRIOR ART

Adult Respiratory Distress Syndrome (ARDS) is a descriptive expressionwhich is applied to a large number of acute, diffuse infiltrativepulmonary lesions of differing etiology if they are associated with asevere gas exchange disorder (in particular arterial hypoxemia). Theexpression ARDS is used because of the numerous clinical andpathological features common with Infant Respiratory Distress Syndrome(IRDS). If, in the case of IRDS, the lung surfactant deficiency causedby premature birth is predominant, then in the case of ARDS a lungsurfactant malfunction is caused by the lung condition based ondiffering etiologies.

Triggering causes for ALI (Acute Lung Injury) including ARDS can, forexample, be (cited in accordance with Harrison's Principles of InternalMedicine 10th Ed. 1983 McGraw-Hill Int. Book Comp.) diffuse pulmonaryinfections (e.g. due to viruses, bacteria, fungi), aspiration of, forexample, gastric juice or in the case of near-drowning, inhalation oftoxins or irritants (e.g. chlorine gas, nitrogen oxides, smoke), director indirect trauma (e.g. multiple fractures or pulmonary contusion),systemic reactions to inflammations outside the lung (e.g. hemorrhagicpancreatitis, gram-negative septicemia), transfusions of high bloodvolumes or alternatively after cardiopulmonary bypass.

With a mortality of 50–60% (survey in Schuster Chest 1995, 107:1721–26),the prognoses of an ARDS patient are still to be designated asunfavourable.

The therapy of ARDS consists mainly in the earliest possible applicationof different forms of ventilation [e.g. PEEP (positive end-expiratorypressure), raising of the oxygen concentration of the respiratory air,SIMV (Synchronized Intermittent Mandatory Ventilation; Harrison'sPrinciples of Internal Medicine 10th Ed 1983 McGraw-Hill Int. BookComp)] up to extracorporeal membrane oxygenation (ECMO; Zapol andLemaire Adult Respiratory Distress Syndrome, Marcel Dekker Inc. 1991).

The specific use of various ventilation techniques has only led to asmall lowering of mortality and includes the risk of setting in motion avicious circle. By ventilation with pressure and high FiO₂ (Fraction ofInspired Oxygen; proportion of oxygen in the respiratory air), the lungsthemselves can be damaged and as a result of this even higher pressuresand higher FiO₂ may be required in order to obtain an adequateoxygenation of the blood.

Nowadays different pharmacological approaches to the solution are alsofollowed. These include lung surfactant substitution [survey, forexample B. Lachmann, D. Gommers and E. P. Eijking: Exogenous surfactanttherapy in adults, Atemw.-Lungenkrkh. 1993, 19:581–91; T. J. Gregory etal.: Survanta supplementation in patients with acute respiratorydistress syndrome (ARDS), Am. J. Respir. Crit. Care Med. 1994, 149:A567]up to purely antiinflammatory therapy with, for example, prostaglandinE₁ (PGE₁; Abraham et al. Crit Care Med 1996, 24:10–15) orglucocorticosteroids (Bernard et al. N Engl J Med 1987, 317:1565–70).Although specific successes were achieved by the administration of lungsurfactant (e.g. Walmrath et al. Am J Resp Crit Care Med 1996,154:57–62), the purely antiinflammatory therapies led to few to nosuccesses. This is in direct contrast to the pathological orhistopathological findings in ARDS. Thus massive polymorphonuclearleucocyte infiltrations (survey, for example Thiel et al. Anesthesist1996, 45:113–130) were found in the lungs and the lavage of patientswith ARDS and a number of inflammatory mediators are detectable. Intesting, PGE₁ is additionally present in a liposomal intravenousadministration form (Abraham et al. Crit Care Med 1996, 24:10–15) aswell as substances which aim at the inhibition of phosphatidic acids(e.g. Lisofylline; Rice et al. Proc Natl Acad Sci 1994, 91:3857–61) orrecombinant human interleukin 1 (IL-1) receptor antagonists (Fisher etal. JAMA 1994, 271:1836–43). Both PGE₁ and the IL-1 receptor antagonist,however, are restricted in their therapeutic utility by side effects.

WO98/35683 indicates compositions for the treatment of ARDS and IRDSwhich containN-(3,5-dichloropyrid-4-yl)-3-cyclopropylmethoxy-4-difluoromethoxybenzamideand lung surfactant. WO96/09831 indicates compositions for the treatmentof ARDS and IRDS which contain a glucocorticosteroid and lungsurfactant. EP-B-0 451 215 describes compositions for the administrationof a pharmaceutical active compound via the lungs. These compositionsinclude liposomes which contain a pharmaceutical active compound and alung surfactant protein. EP-B-0 055 041 describes preparations forinhalation or infusion for the treatment of disorders of the respiratoryorgans, which contain an active compound against disorders of therespiratory organs and natural lung surfactant. Compositions for thetreatment of ARDS and IRDS are not disclosed.

FIGURE LEGENDS

FIG. 1: Time course of PaO₂ [mean±SD] in the experimental groups.C1-INH: 200 U/kg b.w. C1-INH applied intraarterially. LSF: 25 mg/kg b.w.r-SP-C surfactant applied intratracheally.

FIG. 2: Histopathological grading for hyaline membrane formation,neutrophil infiltration, bleedings and edema. Data are presented as meanseverity grades of all six individual animals per group after codedhistopathological evaluation. C1-INH: 200 U/kg b.w. C1-INH appliedintraarterially. LSF: 25 mg/kg b.w. r-SP-C surfactant appliedintratracheally.

DESCRIPTION OF THE INVENTION

It has now surprisingly been found that by the administration of acombination of C1-inhibitor and lung surfactant a synergistic effect canbe achieved in the treatment of IRDS and ALI, including ARDS.

In a first aspect the invention relates to a pharmaceutical compositionfor the treatment of IRDS and ARDS comprising C1-inhibitor incombination with lung surfactant.

Further embodiments of the invention follow from the Patent claims.

In connection with the invention C1-inhibitor (hereinafter also referredto as C1-INH) refers to a protein, designated C1-inhibitor according tothe ability to inhibit e.g. C1-esterase of the complement system and thebradykinin/kinin system. C1-inhibitor can be prepared by isolation fromblood plasma according to methods known in the art. A process forproduction of C1-inhibitor for therapeutic purposes for example isdisclosed in EP 0 101 935. A commercially available product comprisingC1-inhibitor which may be mentioned is Berinert® HS [Centeon Pharma,Marburg (Lahn), Germany]. Berinert® is used in connection with thetreatment of hereditary angioedema and congenital deficiency.

Lung surfactant is understood according to the invention as meaning thenumerous known compositions and their modifications which have thefunction of natural lung surfactant. Natural lung surfactant hassurface-active properties and reduces the surface tension in thealveolar region of the lungs. A simple and rapid quantitative in vitroassay to determine the surface activity of a surfactant preparation ise.g. the Wilhelmy balance [Goerke, J Biochim Biophys Acta, 344:241–261(1974); King R. J. and Clements J. A., Am J Physiol 223:715–726 (1972)].It gives an indication of surfactant quality in terms of the ability toapproach a surface tension of near zero mN/m. It is performed byinjecting a surfactant suspension at defined concentrations ofphospholipids into a hydrous solution. The phospholipids spread to theair-liquid phase building a so-called monolayer. This monolayer reducesthe surface tension of the hydrous solution. A platinum plate iscarefully dipped into the solution. Now the force which pulls down theplatinum plate can be measured with sensitive transducers. This force isproportional to the surface tension and depends on the dimensions of theplatinum plate. An other method to describe the surface activity ofsurfactant preparations is the pulsating bubble surfactometer [PossmayerF., Yu S. and Weber M., Prog Resp Res, Ed.v. Wichert, Vol. 18:112–120(1984)]. The activity of a surfactant preparation can also be assessedby an in vivo assay, for example, as described below in the sectionPharmacology or in an assay as described by Häfner et al. (D. Häfner etal.: Effects of rSP-C surfactant on oxygenation and histology in a ratlung lavage model of acute lung injury. Am. J. Respir. Crit. Care Med.1998, 158: 270–278). Measurement of lung compliance, blood gases andventilator pressure will provide indices of activity.

Lung surfactant is to be understood according to the inventionpreferentially as compositions which will show activity in such anassay. Particular mention may be made of compositions which will show anactivity in such an assay similar or greater to that of natural, inparticular human, lung surfactant.

In particular lung surfactant compositions comprise phospholipids andinter alia can additionally contain lung surfactant proteins. Preferredphospholipids which may be mentioned in connection with the inventionare dipalmitoylphosphatidylcholine (DPPC),palmitoyloleylphosphatidylglycerol (POPG) and/or phosphatidylglycerol(PG). Preferably the phospholipids are mixtures ofdipalmitoylphosphatidylcholine (DPPC) andpalmitoyloleylphosphatidylglycerol (POPG), in particular in a ratio from7 to 3, to 3 to 7. Possible lung surfactant proteins are both theproteins obtained from natural sources, such as, for example, pulmonarylavage or extraction from amniotic fluid, and also synthetically orgenetically engineered proteins. According to the invention, the lungsurfactant proteins designated by SP-B and SP-C and their modifiedderivatives are particularly of interest. The amino acid sequences ofthese lung surfactant proteins, their isolation or preparation bygenetic engineering are known (e.g. from WO-86/03408, EP-A-0 251, 449,WO-89/04326, WO-87/06943, WO-88/03170, EP-A-0 368 823 and EP-A-0 348967). Modified derivatives of SP-C which differ from human SP-C byreplacement of certain amino acids are disclosed for example inWO91/18015 and WO95/32992. Particular mention may be made of the SP-Cderivatives disclosed in WO95/32992. According to the inventionsurfactant protein in particular refers to a recombinant SP-C derivative[hereinafter referred to as r-SP-C or r-SP-C (FF/I)] which differs fromhuman SP-C by replacement of the two cysteines in position 4 and 5 byphenylalanine and replacement of the methionine in position 32 byisoleucine. The term lung surfactant protein as used herein also refersto mixtures of different lung surfactant proteins.

Further components which may be present in lung surfactant compositionsare fatty acids, for example palmitic acid. The lung surfactantcompositions may also contain electrolytes such as calcium, magnesiumand/or sodium salts (for example calcium chloride, sodium chlorideand/or sodium hydrogen carbonate), to set a favourable viscosity. Theskilled worker will base his determination of the type and amount ofindividual constituents of the lung surfactant composition on the onehand on the known composition of natural pulmonary surfactant, and onthe other hand on the numerous proposals in the prior art, such as forexample, EP-A 0119056 and EP-A 0406732.

EP-B-0 100 910, EP-A-0 110 498, EP-B-0 119 056, EP-B-0 145 005 andEP-B-0 286 011 describes phospholipid compositions with and without lungsurfactant proteins which are suitable, for example, as components ofthe preparations according to the invention.

Commercially available products which may be mentioned are Curosurf®(Serono, Pharma GmbH, Unterschleissheim), a highly purified naturalsurfactant from homogenized pigs' lungs, Survanta® (Abbott GmbH,Wiesbaden) and Alveofact® (Dr. Karl Thomae GmbH Biberach), both extractsof bovine lungs, and also Exosurf® (Deutsche Wellcome GmbH, Burgwedel),a synthetic phospholipid with auxiliaries.

Lung surfactant compositions in connection with the inventionexpediently contain 80 to 95% by weight of phospholipids, 0.2 to 5% byweight of surfactant protein, 2 to 15% by weight of fatty acids and 0 to5% by weight of elektrolytes (of the dry mass).

Preferred lung surfactant compositions in connection with the inventioncontain 80 to 95% by weight of phospholipids, 0.5 to 3.0% by weight ofsurfactant protein, 3 to 15% by weight of fatty acids and 0 to 3% byweight of calcium chloride (of the dry mass).

Particularly preferred lung surfactant compositions in connection withthe invention contain 80 to 95% by weight of phospholipids, 0.5 to 3.0%by weight of surfactant protein, 4 to 7% by weight of fatty acids,preferably palmitic acid and 1 to 3% by weight of calcium chloride (ofthe dry mass).

In connection with the invention combination means fixed, and freecombinations, i.e. either C1-INH and lung surfactant are presenttogether in one dosage unit, or C1-INH and lung surfactant, which arepresent in separate dosage units, are administered in direct successionor at a relatively large time interval; a relative large time intervalmeans a time span up to a maximum of 24 hours. For use as separatedosage units, these are preferably made available together in one pack.

Separate dosage units for lung surfactant and C1-INH are prepared byprocedures familiar to those skilled in the art, if appropriate usingfurther suitable pharmaceutical auxiliaries. Preferably C1-INH ispresent in lyophilized form in connection with separate dosage units. Asuitable product is known in the art under the trademark Berinert® HS.The preparation of a lung surfactant composition can be achieved bymethods known to those skilled in the art, for example by incorporationof a surfactant protein into a phospholipid matrix, for example asdescribed in WO95/32992. In connection with the invention, the lungsurfactant compositions are made available preferably in lyophilizedform and in particular in spray dried form. Lyophilized compositions arefor example known from WO97/35882, WO95/32992, WO91/00871 and DE3229179. WO97/26863 describes a process for the production of a lungsurfactant composition in powder form by means of spray drying.

In connection with fixed combinations, the compositions according to theinvention are prepared by procedures familiar to those skilled in theart, if appropriate using further suitable pharmaceutical auxiliaries. Apowder form is obtained, for example, by directly mixing powdered formsof C1-INH and lung surfactant or by mixing liquid lung surfactantpreparations, e.g. aqueous suspensions, with aqueous solutions of C1-INHand then lyophilizing and micronizing it. Alternatively, a solution of alung surfactant and C1-INH can be lyophilized in a suitable solvent,such as, for example, isopropanol, and then micronized. Spray-drying ofa mixture of an aqueous lung surfactant suspension and an aqueous C1-INHsolution or a solution of a lung surfactant and C1-INH in suitablesolvents, such as alcohols, (e.g. methanol, ethanol, 2-propanol)chloroform, dichloromethane, acetone and their mixtures, whichoptionally can additionally contain water may also leads to powderedpreparations.

Pharmacology

Materials and Methods

Animal Preparation

The study protocol was reviewed and approved by the Laboratory AnimalCare Committee at the district presidency of Freiburg, Germany inaccordance with guidelines for ethical animal research. The study wasperformed with a total of 36 male Sprague Dawley rats (Harlan CBP,Zeist, The Netherlands), with a body weight (b.w.) of 242–264 g.

After induction of general anesthesia with halothane and nitrous oxidein oxygen an indwelling catheter was placed into one carotid artery.After intraperitoneal (i.p.) injection of pentobarbital (60 mg/kg b.w.)the rats were tracheotomized and a tube was secured into the trachea ofeach animal. Before mechanical ventilation was started the animalsreceived an intramuscular (i.m.) injection of pancuronium bromide (2mg/kg b.w.). The tracheal tubes of six animals were connected to adistributor and animals were ventilated simultaneously using a Servo 900C ventilator (Siemens Elema, Solna, Sweden) at a respiratory rate of 30breaths/min, a fraction of inspired oxygen (FiO₂) of 1.0, aninspiration/expiration ratio of 1:2, a peak inspiratory pressure (PIP)of 15 cm H₂O and a positive end-expiratory pressure (PEEP) of 2 cm H₂O.Additional pentobarbital (i.p., 15 mg/kg b.w.) and pancuronium bromide(i.m., 2 mg/kg b.w.) were given when appropriate.

C1-Inhibitor

Pasteurized human C1-Inhibitor (Berinert® HS, Centeon, Germany) wasresuspended with 9 ml physiological (0.9%) saline solution to achieve aconcentration of 50 units (U)/ml. One unit is the amount of C1-INHpresent in 1 ml of normal human plasma (equal to 270 μg). Animalstreated with C1-Inhibitor received 200 U/kg b.w. intraarterially.

Surfactant

r-SP-C surfactant (Byk Gulden, Germany) contains 2% recombinantsurfactant protein C (r-SP-C is an analog of human SP-C that hasphenylalanine instead of two cysteines in positions 4 and 5 of the humanSP-C sequence, and isoleucin in position 32 instead of methionine)embedded in a phospholipid matrix. It consists ofdipalmitoylphosphatidylcholine and palmitoyloleoylphosphatidylglycerolat a ratio of 70:30 plus 5% (w/w) palmitic acid as related tophospholipids (PL). The r-SP-C surfactant was resuspended withphysiological (0.9%) saline solution to achieve a concentration of 25 mgPL per ml. Surfactant was instilled intratracheally (i.t.) as bolus of25 mg PL per kg body weight in a volume of 1.2 ml per animal. The r-SP-Csurfactant was diluted with 0.9% saline solution to achieve the requiredconcentration of 6.25 mg total PL per 1.2 ml.

Experimental Protocol

After instrumentation, blood samples were withdrawn from the arterialcatheter for baseline determination of blood gases and C1-INH levels.Only animals with PaO₂ values of more than 480 mmHg were included in theexperiments. Peak inspiration pressure (PIP) was raised to 28 cm H₂O andPEEP to 8 cm H₂O and the animals were subjected to multiple lung lavage(6–8 times) with 1 ml/30 g b.w. of isotonic saline solution. To avoidmetabolic acidosis, 4 ml/kg b.w. of a glucose/NaHCO₃ solution (5 gglucose-monohydrate and 8.4 g NaHCO₃ dissolved in 100 ml 0.9% NaClsolution) were given by i.p. injection to each animal after lavage.Administration of glucose/NaHCO₃ was repeated if arterial HCO₃ ⁻decreased below 20 mmol/1 during the experiment. Blood gases weredetermined at 5, 30, and 60 min after the last lavage using an ABL-500blood gas analyzer (Radiometer, Copenhagen, Denmark). Only animals withPaO₂ values between 50 and 110 mmHg after the lavage procedure wereincluded in the study.

Four experimental groups and two control groups were studied: In group 1the animals were sacrificed one hour after the last lavage and in group2 the animals were sacrificed at 210 min after the last lavage and theseanimals did not receive any treatment. In group 3 C1-INH (200 U/kg b.w.)was administered 60 minutes after the last lavage (p.l.). In group 4 theanimals received 25 mg/kg b.w. r-SP-C surfactant at 60 min. p.l. Ingroup 5 the animals were treated with C1-INH and r-SP-C surfactant at 60min. p.l. In group 6 C1-Inhibitor was administered at 10 min. p.l.Subsequently, blood gases were determined 90, 120, 150, 180 and 210 minafter the last lavage. During the whole experimental period PIP and PEEPwere kept constant at 28 cm H₂O and 8 cm H₂O, respectively. The animalswere sacrificed at 210 minutes after the last lavage procedure.

Preparation of the Lungs

The lungs were carefully excised en bloc and fixed for 24 h in 8%phosphate-buffered formalin. Following fixation blocks of all lobes weresectioned and stained with haematoxylin and eosin (HE). Afterrandomization and codification each section was examined under lightmicroscopy. Hyaline membrane formation was assessed semiquantitativelyaccording to the previously used technique (D. Häfner et al.: Effects ofrSP-C surfactant on oxygenation and histology in a rat lung lavage modelof acute lung injury. Am. J. Respir. Crit. Care Med. 1998, 158:270–278). The severity of hyaline membrane formation was graded 0 to4+(0, no hyaline membrane formation; 1+, occasional fields showinghyaline membrane formation in a low number (1–3) of membranes per viewedfield (minimal); 2+, occasional fields showing hyaline membraneformation in an increased number (>3) of membranes per viewed field(mild); 3+, many but not all fields showing hyaline membrane formation(moderate); 4+, hyaline membrane formation in all fields examined(severe)). The distribution and severity of intraalveolar accumulationof PMNL's were graded semiquantitatively from 0 to 4+ comparable to thegrading of hyaline membrane formation but with respect to the number ofinflammatory cells and the location of these cells. The severity ofintra-alveolar and perivascular hemorrhage were gradedsemiquantitatively using the same scale from 0 to 4+.

Sampling Procedure and C1-INH Assay

Blood samples for C1-INH determination were obtained at baseline and at210 min. p.l. from the arterial catheter and placed into plastic tubescontaining 3.8% sodium citrate. Plasma was obtained from blood samplescentrifuged for 15 minutes at 2.500 g. All samples were stored at minus700 Celsius. The activity of C1-Inhibitor was measured by an amidolyticmethod using an excess of C1-Esterase and C₂H₅Co-Lys(E-Cbo)-Gly-Arg-pNaas substrate (Berichrom C1-INH, Behring Diagnostics, Marburg, Germany).In this assay C1-INH inhibits cleavage of the chromogenic substrate byC1-Esterase. C1-INH activity of the samples was calculated from areference curve prepared from human standard plasma.

Statistics

Results are presented as mean±standard deviation. Overall variationsduring the study protocol were analyzed using Kruskal-Wallis tests(nonparametric one-way analysis of variance). Subsequent comparisonsbetween groups were analyzed using Wilcoxon tests and adjusted formultiple testing. All tests were two-tailed and a p<0.05 was consideredstatistically significant.

Results

Oxygenation

The arterial oxygen tension decreased from 530±14 mmHg (baseline) to84±10 mmHg after the lavage procedure. No animal of the control groupshowed a spontaneous increase in arterial pO₂ during the experimentalperiod. Arterial pO₂ increased significantly to 496±54 mmHg in group 4(r-SP-C surfactant) and to 446±65 mmHg in group 5 (r-SP-C surfactant andC1-INH) at 30 minutes and remained high until sacrifice. PaO₂ values ofanimals treated with C1-Inhibitor only were comparable to controls witha tendency towards higher paO₂ values in animals receiving C1-INH at 60minutes postlavage. FIG. 1 summarizes the effects of C1-INH and r-SP-Csurfactant administration on arterial pO₂.

C1-Inhibitor

Baseline levels of C1-Inhibitor activity were 44±12% of human standardplasma. In the groups treated with C1-INH concentrate (group 3, 5 and6), plasma levels increased to 210±41%. In the control groups (group 1and 2) and animals treated with r-SP-C surfactant only (group 4) C1-INHactivity remained at 36±14%.

Histopathological Evaluation

The gradings for the observed histopathological changes are presented inFIG. 2. In untreated controls only moderate hyaline membrane formationwas present in the lungs at 60 minutes after the last lavage. The meanseverity of hyaline membrane formation increased during the experimentfrom 2.50 at 60 minutes p.l. up to 3.16 at sacrifice. In addition tothat, the grading for intravascular and intraalveolar granulocytes(margination of polymorphonuclear neutrophil leukocytes, PMNL), theintraalveolar bleedings and the formation of edema showed a similartime-dependant increase.

At 210 minutes after lavage, the formation of hyaline membranes wassignificantly reduced in group 3 (r-SP-C surfactant, see FIG. 2). Thecombination of r-SP-C surfactant with C1-INH (group 4) and C1-INHmonotherapy 60 minutes after lavage (group 5) showed a comparable effecton the prevention of hyaline membrane formation to r-SP-C surfactantmonotherapy (FIG. 2). CL-INH administration at 10 minutes after lavage(group 6) had only a minor effect on the prevention of hyaline membraneformation (FIG. 2). The intratracheal application of r-SP-C surfactant(group 3) lead to an increase in the histopathological gradings forintravascular and intraalveolar granulocytes, for intraalveolarbleedings and edema in comparison to the particular mean severitygradings of the 210 minutes control group (group 2) as shown in FIG. 2.The observed histopathological changes after r-SP-C surfactantmonotherapy were less severe when r-SP-C surfactant was combined withCL-INH (FIG. 2). C1-Inhibitor monotherapy (group 5 and 6) reducedsignificantly the histopathological gradings for intravascular andintraalveolar granulocytes, for intraalveolar bleedings and edemaformation (FIG. 2).

In the investigation of compositions according to the inventioncomprising C1-INH and lung surfactant in this model, it was found thatthe oxygenation and the histological changes improve synergistic incomparison with the sole administration of lung surfactant or C1-INH.Based on this unexpected result it can be concluded that by using acombination of C1-INH and lung surfactant the treatment of IRDS and ALI(including ARDS) can be shortened and the high mortality accompanyingthese syndromes can be reduced. Additionally it is possible either tosave a portion of the very expensive LSF or to attain an enhanced effectof each of the components.

Commercial Utility

Adult Respiratory Distress Syndrome (ARDS) is a descriptive expressionwhich is applied to a large number of acute, diffuse infiltrativepulmonary lesions of differing etiology if they are associated with asevere gas exchange disorder (in particular arterial hypoxemia). Theexpression ARDS is used because of the numerous clinical andpathological features common with Infant Respiratory Distress Syndrome(IRDS). If, in the case of IRDS, the lung surfactant deficiency causedby premature birth is predominant, then in the case of ARDS a lungsurfactant malfunction is caused by the lung condition based ondiffering etiologies.

Triggering causes for ALI (Acute Lung Injury) including ARDS can, forexample, be (cited in accordance with Harrison's Principles of InternalMedicine 10th Ed. 1983 McGraw-Hill Int. Book Comp.) diffuse pulmonaryinfections (e.g. due to viruses, bacteria, fungi), aspiration of, forexample, gastric juice or in the case of near-drowning, inhalation oftoxins or irritants (e.g. chlorine gas, nitrogen oxides, smoke), director indirect trauma (e.g. multiple fractures or pulmonary contusion),systemic reactions to inflammations outside the lung (e.g. hemorrhagicpancreatitis, gram-negative septicemia), transfusions of high bloodvolumes or alternatively after cardiopulmonary bypass.

The compositions according to the invention are not only suitable forthe treatment or prophylaxis of IRDS in premature babies and for thetreatment or prophylaxis of ALI including ARDS in adults in particularin connection with multiple organ failure, but also for the treatment orprophylaxis of pneumonia, bronchitis, meconium aspiration syndrome, COPD(chronic obstructive pulmonary disease), asthma and cystic fibrosis.

The administration of the compositions according to the invention isaccomplished according to methods known by those skilled in the art.Preferably the compositions according to the invention are dissolved orresuspended in a suitable solvent or resuspension medium foradministration. This is particularly preferred in case of spray dried orlyophilized compositions. Preferably physiological saline solution isused as suitable resuspension medium. It may be advantageous toadminister suspensions or solutions of the compositions according to theinvention which contain from 6,25 to 100 mg phospholipids per mlsuspension or solution. It is preferred to administer (per singleadministration) suspensions or solutions of the compositions accordingto the invention which contain from 6,25 to 200 mg phospholipids andfrom 1 to 600 IU mg C1-INH per kg body weight. In connection withpulmonary application it is preferred to administer from 1 to 60 IUC1-INH per kg body weight and in connection with systemic application itis preferred to administer from 6 to 600 IU C1-INH per kg body weight.Expediently the compositions are administered one to three times a day,for a period from one to seven days. In connection with systemicapplication of the C1-INH it is preferred to administer 6 to 600 IUC1-INH per kg body weight as bolus and 3 to 300 IU C1-INH per kg bodyweight per day as continuous infusion for the next three to four days.

In connection with fixed combinations the administration of thepharmaceutical composition is preferably accomplished by intratrachealinstillation (infusion or bolus) or by way of atomization.

In connection with free combinations the administration of the lungsurfactant composition is preferably accomplished by intratrachealinstillation (infusion oder bolus) or by way of atomization and theadministration of the C1-INH composition is preferably accomplished byinjection or infusion. In case of separate dosage units, C1-INH and lungsurfactant are administered in direct succession or at a relativelylarge time interval; a relative large time interval means a time span upto a maximum of 24 hours.

If desired, prior to administration of the compositions according to theinvention a bronchoalveolar lavage, preferably with diluted lungsurfactant suspension, can be carried out. Such a treatment is forexample described by Gommers et al. [Bronchoalveolar lavage with adiluted surfactant suspension prior to surfactant instillation improvesthe effectiveness of surfactant therapy in experimental acuterespiratory distress syndrome (ARDS), Intensive Care Med. 1998,24:494–500] and in WO98/49191.

The invention furthermore relates to a method for the treatment ofmammals, including humans, who are suffering from pneumonia, bronchitis,meconium aspiration syndrome, COPD (chronic obstructive pulmonarydisease), asthma, cystic fibrosis, IRDS and/or ALI (including ARDS). Themethod is characterized in that a therapeutically active andpharmacologically effective and tolerable amount of the compositionaccording to the invention is administered to the sick mammal.

The invention further relates to the use of a composition according tothe invention for the production of medicaments for the treatment ofpneumonia, bronchitis, meconium aspiration syndrome, COPD (chronicobstructive pulmonary disease), asthma, cystic fibrosis, IRDS and/or ALI(including ARDS).

Further subject of the invention is an article of manufacture comprisingcustomary secondary packaging material and a pharmaceutical compositionin a suitable primary packaging material (for example an ampoule orvial) contained within the secondary packaging material, wherein thepharmaceutical composition comprises C1-INH in combination with lungsurfactant, optionally together with suitable pharmaceutical auxiliaries(for example saline solution for resuspension of active agents in caseof powdered forms), and wherein the primary and/or secondary packagingmaterial comprises a label or package insert which indicates that thepharmaceutical composition is useful for preventing or treatingpneumonia, bronchitis, meconium aspiration syndrome, COPD (chronicobstructive pulmonary disease), asthma, cystic fibrosis, IRDS and/or ALI(including ARDS). The secondary packaging material, the primarypackaging material and the label or package insert may comply with whatis considered as standard for pharmaceutical compositions of this kindby those skilled in the art.

1. A pharmaceutical composition comprising C1-inhibitor (C1-INH) andlung surfactant, wherein the lung surfactant comprises a lung surfactantprotein.
 2. A pharmaceutical composition as claimed in claim 1, whereinCI-INH and the lung surfactant are present in a fixed combination.
 3. Apharmaceutical composition as claimed in claim 1, wherein the lungsurfactant contains a mixture of phospholipids.
 4. A pharmaceuticalcomposition as claimed in claim 3, wherein the phospholipids arephospholipids which occur in natural lung surfactant.
 5. Apharmaceutical composition as claimed in claim 1 wherein lung surfactantprotein contains SP-B, SP-C, their modified derivatives, or mixtures ofSP-B, SP-C and/or their modified derivatives, wherein said modifiedderivatives reduce the surface tension in the alveolar region of thelungs.
 6. A pharmaceutical composition as claimed in claim 1, whereinthe lung surfactant is obtained by pulmonary lavage.
 7. A method oftreating or preventing a disease or disorder selected from the groupconsisting of pneumonia, bronchitis, meconium aspiration syndrome, COPD(chronic obstructive pulmonary disease), asthma, cystic fibrosis, IRDS(Infant Respiratory Distress Syndrome), ALI (Acute Lung Injury), andARDS (Adult Respiratory Distress Syndrome) in a patient, comprisingadministering to a patient in need thereof a therapeutically effectiveamount of the pharmaceutical composition as claimed in claim
 1. 8. Acommercial product comprising a primary packaging which contains apharmaceutical composition, and secondary packaging, wherein thepharmaceutical composition comprises C1-INH and lung surfactant whereinthe lung surfactant comprises a lung surfactant protein, and wherein theprimary and/or secondary packaging comprises a label or package insertwhich indicates that the pharmaceutical composition is useful forpreventing or treating one or more diseases or disorders selected fromthe group consisting of pneumonia, bronchitis, meconium aspirationsyndrome, COPD (chronic obstructive pulmonary disease), asthma, cysticfibrosis, IRDS (Infant Respiratory Distress Syndrome), ALI (Acute LungInjury), and ARDS (Adult Respiratory Distress Syndrome).